North Toronto Health Collaboration Ontario Health Team Appendices

May 15, 2019 Self-Assessment Submission List of Appendices

1. Ontario Health Team: Submitting Members (slide 3) 2. North Toronto Health Collaboration: Vision (slide 4) 3. North Toronto Health Collaboration: Guiding principles (slide 5) 4. North Toronto Health Collaboration: Goals (slide 6) 5. North Toronto Health Collaboration: Statement of Intent (slides 7-9) 6. North Toronto Health Collaboration: Partnership List (slide 10) 7. Geographic Catchment (slide 11) 8. Primary Care and Community Committee (PCCC): Purpose & Membership (slide 12) 9. Seamless Care Optimizing the Patient Experience (SCOPE) (slide 13) 10. North Toronto Sub-Region Advisory Council: Membership List (slides 14-15) 11. North Toronto Sub-Region Advisory Council: Terms of Reference (slide 16) 12. Palliative Care Journey Committee: Terms of Reference (slide 17) 13. Palliative Care Journey Committee: Network of Partners (slide 18) 14. Sunnybrook Data: Seniors (slides 19-26) 15. North Toronto Neighbourhood-level Data (slides 27-31) 16. North Toronto Neighbourhood Care (slides 32-34) 17. Patient, Family, and Caregiver Engagement Committees and Activities (slide 35) 18. North Toronto Areas of Activity (slide 36) 19. Building & Integrated Primary Care in Toronto (slide 37)

2 1. Ontario Health Team: Submitting Members

3 2. North Toronto Health Collaboration: Vision

• Our vision is to become one connected system of health care for people living and seeking care in North Toronto* • This means working together to connect a complete continuum of care that meets the needs of local citizens • In the eyes of our community, care will be simple to access, it will be coordinated, and providers will communicate as One Team • We are committed to coordinating care around the people in need of care, not providers • We recognize that this has yet to be achieved in Ontario and we are committed to learning how to achieve this • As we move forward, we will be guided by our shared principles

*While we are connecting care within the natural catchment area of North Toronto, we are doing so in a way that: • Does not create boundaries (real or perceived) that would limit peoples’ access • Respects the multiple accountabilities that we collectively hold, such as the care we provide beyond North Toronto

4 3. North Toronto Health Collaboration: Guiding principles

• We are guided by the needs of communities and the people we serve (community over organization) • Build a system that responds to what we have heard • Respectfully engage clients / patients and communities • Respect diversity (guided by the citizen voice) and maximize equity (inform investments)

• Success will require strong and engaged leadership of the partnership / network

• Implementation will be underpinned by a willingness and commitment to learning and continuous improving (rapid adaptation) • This is an evolving / evolutionary process • Development is evidence-informed and will be supported with timely evaluation

• We will capitalize and build on what has been accomplished to date • Adopt values defined by the Local Collaborative (person-centred, transparent, cooperative, inclusive, leading change)

• Process will be inclusive and transparent both within the participant membership and with our partners in our communities • Will be implemented through a collaborative / participatory model and on a voluntary basis • This is a system approach • Committed to consistency in messaging and how we communicate 5 4. North Toronto Health Collaboration: Goals

1. Everyone is able to access and 4. Every health care provider will be 6. Performance measures will: navigate health care in the North connected as part of one system of • Reflect population health status • Access to care that meets needs care, including primary care • Support self navigation and health and health equity literacy • Providers will work as one team • Reflect client and community and one brand will be built experience 2. Every person will have access to primary and team-based care when • Providers will work as one team • Track value needed • Communication will happen in a • Show improvement in what we • All residents of North Toronto will timely manner have the opportunity to be rostered, do enrolled, or attached to primary care • Platforms will be interoperable Transparent access targets will be • All residents will have choice and flexibility in where they can receive published primary care 5. Leadership and governance model • Primary care will be available when people need it and urgent care will will reflect shared accountability 7. Providers will be jointly committed be offered and collaboration across primary to continuous improvement and care, community-based care, and connecting with social services 3. People and providers will be satisfied hospital care with the coordination available to them • One collaborative Quality • Will be achieved by building on the • Shared accountability will be Improvement Plan (cQIP) will be community assets available in North established published Toronto • Gains and risks will be shared • The network will actively engage across providers partners to contribute to improving social determinants of health

8. Investment will be targeted to meeting need

6 5. North Toronto Health Collaboration: Statement of Intent (Part 1)

7 5. North Toronto Health Collaboration: Statement of Intent (Part 2)

8 5. North Toronto Health Collaboration: Statement of Intent (Part 3)

9 6. North Toronto Health Collaboration: Partnership List

• Bolded partners have signed the Statement of Intent to be part of ‘North Toronto Health Collaboration’ • Non-bolded organizations have shown interest and / or we feel there is alignment with the mission / purpose of the North Toronto OHT and we hope to engage further with • We recognize our partnership list will grow to reflect our governance model; as such not all organizations could be listed at this time

Citizen / Patient Hospital & Community Support Home Care & Primary Care Community MH&A Other Advisor Ambulatory Services Community Support

Leslie Millrod Unison LOFT Baycrest Hospital SPRINT Senior Care Home & Toronto Paramedic Citizen Advisor Michelle Joseph, CEO Heather McDonald, CEO William Reichman, CEO Stacy Landau, CEO Community Care Services Tess Romain, Acting CEO

Vibrant Healthcare Bellwood Health Services Sunnybrook Alzheimer’s Society SE Health Simone Atungo, CEO Joe Manget, CEO Andy Smith, CEO of Toronto Shirley Sharkee, CEO Scott Russell, CEO

SHSC Dept. Family & Skylark Bellwoods Centres VHA Home Healthcare Community Medicine Lydia Sai-Chew, CEO for Community Living Carol Annett, CEO Dr. Karen Fleming Lori Holloway, CEO

Centres d'Accueil Héritage Dr. Yoell Abels Barbara Ceccarelli Forest Hill Family Health Centre Directrice générale / Executive Director Dr. Jocelyn Charles Physician advisor, Primary Care PACE Independent Living TC LHIN Laura Viser, Executive Director,

Interprofessional Primary Care Team Baycrest Hospital

Integrated Community Care Team Baycrest Hospital

Sunnybrook Academic FHT 10 7. Geographic Catchment

203,700 Area: 39 km2 13 City of Toronto Neighbourhoods Population Density: 5,244.4 persons per km2 Males: 46.2% Females: 53.9% % Seniors (ages 65+): 16.0% (32,615 individuals)

11 8. Primary Care and Community Committee (PCCC): Purpose & Membership The North Toronto PCCC works proactively with Primary Care to create a network that identifies population and primary care needs and responds by engaging health and social system partners to co-develop innovative direct care service delivery models.

Member Name Address Email Physician Model Dr. Yoel Abells 491 Eglinton Avenue West 2nd Floor, Toronto ON M5N 1A8 [email protected] FHG (PCCL/Chair) Sunnybrook Health Sciences Centre Room C114 Dr. Dan Cass [email protected] NA 2075 Bayview Avenue, Toronto ON M4N 3M5 Toronto Central Local Health Integration Network Wilfred Cheung [email protected] NA 250 Dundas Street West, Suite 305, Toronto, ON M5T 2Z5 Sunnybrook Health Sciences Centre Room A100 Dr. Lisa Del Giudice [email protected] FHT/FHO 2075 Bayview Avenue, Toronto ON M4N 3M5 Sunnybrook Health Sciences Centre Dr. Karen Fleming [email protected] FHO 2075 Bayview Avenue, Toronto ON M4N 3M5 Dr. Steven Gottesman 491 Lawrence Avenue West Suite 100, Toronto ON M5M 1C7 [email protected] FHO Stacy Landau SPRINT Senior Care, 140 Merton Street, 2nd Floor, Toronto, ON M4S 1A1 [email protected] NA Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Kitty Liu [email protected] NA Toronto ON M4N 3M5 Dr. Rivian Miller 245 Eglinton Avenue East, Toronto ON M4P 3B7 [email protected] FHG Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Kittie Pang [email protected] NA Toronto ON M4N 3M5 Unison Health & Community Services, 1651 Keele Street,Toronto ON M6M Dr. Mary Romaniuk [email protected] CHC 3W2 LOFT Community Services, 15 Toronto Street, 9th floor, Toronto ON, M5C Debra Walko [email protected] NA 2E3 Toronto Central Local Health Integration Network Lindsay Wingham-Smith [email protected] NA 425 Bloor Street East, Suite 201, Toronto, ON M4W 3R4 Dr. Patrick Wong Vibrant Healthcare Alliance, 2398 Yonge Street, Toronto ON M4P 2H4 [email protected] CHC 12 9. Seamless Care Optimizing the Patient Experience (SCOPE)

• SCOPE (Seamless Care Optimizing The Patient Experience) is a virtual interprofessional health team that supports primary care providers through a single point of access. • Family physicians and nurse practitioners registered with SCOPE can connect to local specialists, imaging, and community services, to serve their patients with complex care needs.

Current State & Next Steps

SCOPE currently supports over 220 Primary Care Physicians across TC LHIN, including 60+ in North Toronto

SCOPE now offers an expanded suite of services such as headache clinics, RN Health Coaches across more institutions

SCOPE expansion is being evaluated as a Quality Improvement initiative

13 10. North Toronto Sub-Region Advisory Council: Membership List (Part 1)

Active Members Member Name Organization Address Email Dr. Yoel Abells Forest Hill Family Health Centre 491 Eglinton Avenue West 2nd Floor, Toronto ON M5N 1A8 [email protected] (co-chair; PCCL) Stacy Landau SPRINT Senior Care 140 Merton Street, 2nd Floor, Toronto, ON M4S 1A1 [email protected] (co-chair) Simone Atungo Vibrant Healthcare Alliance 2398 Yonge Street, Toronto, ON M4P 2H4 [email protected] Dr. Dan Cass Sunnybrook Health Sciences Centre Room C114, 2075 Bayview Avenue, Toronto ON M4N 3M5 [email protected] Barbara Cawley VHA Home HealthCare 30 Soudan Avenue, Suite 600, Toronto, ON M4S 1V6 [email protected] Dr. Jocelyn Charles Sunnybrook Health Sciences Centre 2075 Bayview Avenue, Toronto ON M4N 3M5 [email protected] Wilfred Cheung Toronto Central Local Health Integration Network 425 Bloor Street East, Suite 201, Toronto, ON M4W 3R4 [email protected] Breanne Ciacco LOFT Community Services 15 Toronto Street, 9th floor, Toronto ON, M5C 2E3 [email protected] Kelly Clarke Toronto Central Local Health Integration Network 250 Dundas Street West, Suite 305, Toronto, ON M5T 2Z5 [email protected] Dr. Carole Cohen Sunnybrook Health Sciences Centre 2075 Bayview Avenue, Toronto ON M4N 3M5 [email protected] Janet Dang Sunnybrook Health Sciences Centre 2075 Bayview Avenue, Toronto ON M4N 3M5 [email protected] Lawrence Heights Site,12 Flemington Road, Toronto, Ontario Judy Downer Unison Health and Community Services [email protected] M6A 2N4 Sharri-Ann Bellwoods Centres [email protected] Edmunds Karen Fleming Sunnybrook Health Sciences Centre 2075 Bayview Avenue, Toronto ON M4N 3M5 [email protected] Jason Fuoco LOFT Community Services (Pine Villa) 15 Toronto Street, 9th floor, Toronto ON, M5C 2E3 [email protected] Yan Gao Don Mills Family Health Team 20 Wynford Drive Suite 200, Toronto ON M3C 1J4 [email protected] Stephanie Greco Patient and Family Advisory Council Representative Lori Holloway Bellwoods Centres [email protected] Tracy Hussey Sunnybrook Health Sciences Centre 2075 Bayview Avenue, Toronto ON M4N 3M5 [email protected] Helene LaCroix Saint Elizabeth Health Care [email protected] Kitty Liu Sunnybrook Health Sciences Centre 2075 Bayview Avenue, Toronto ON M4N 3M5 [email protected] Ann Marie 36 Eglinton Avenue West, Suite 602, Toronto, Ontario M4R Mood Disorders Association of Ontario [email protected] MacDonald 1A1 14 10. North Toronto Sub-Region Advisory Council: Membership List (Part 2)

Active Members Member Name Organization Address Email Kimberly Providence Healthcare 3276 St. Clair Avenue East, Toronto, ON M1L 1W1 [email protected] MacKenzie Linda Mather Patient and Family Advisory Council Co-Chair Carol McFarlane Saint Elizabeth Health Care [email protected] Sunnybrook Health Sciences Centre / Saint [email protected] / Kay McGarvey Elizabeth Health Care [email protected] Kristy McKay Alzheimer Society of Toronto [email protected] Susan Meikle Toronto North Support Services 132 Railside Road, Unit 2, Toronto, ON M3A 1A3 [email protected] Building C, C-02, 3000 Lawrence Avenue East, Keith Menezes Scarborough Academic Family Health Team [email protected] Scarborough ON M1P 2V1 Tory Merritt North York Central Health Link 4001 Leslie Street, Toronto, ON M2K 1E1 [email protected] Citizens’ Panel Representative for the Toronto Leslie Milrod Central Local Health Integration Network Adijatukubra Musa Don Mills Family Health Team 20 Wynford Drive Suite 200, Toronto ON M3C 1J4 [email protected] Dr. Mireille Norris Sunnybrook Health Sciences Centre 2075 Bayview Avenue, Toronto ON M4N 3M5 [email protected] Kittie Pang Sunnybrook Health Sciences Centre 2075 Bayview Avenue, Toronto ON M4N 3M5 [email protected] Cheryl Perera Skylark Children, Youth & Families 40 Orchard View Blvd, Unit 255, Toronto, ON M4R 1B9 [email protected] Ann Phillips Vibrant Healthcare Alliance 2398 Yonge Street, Toronto, ON M4P 2H4 [email protected] Cécile Raymond Circle of Care 4211 Yonge Street, Suite 401, Toronto, ON M2P 2A9 [email protected] Kurt Rose Sunnybrook Health Sciences Centre 2075 Bayview Avenue, Toronto ON M4N 3M5 [email protected] Jagger Smith Baycrest Hospital 3560 Bathurst Street, Toronto, ON, M6A 2E1 [email protected] Dr. Rosalie Sunnybrook Health Sciences Centre 2075 Bayview Avenue, Toronto ON M4N 3M5 [email protected] Steinberg 250 Dundas Street West, Suite 305, Toronto, ON Lisa Walker Toronto Central Local Health Integration Network [email protected] M5T 2Z5 Lindsay Wingham- 425 Bloor Street East, Suite 201, Toronto, ON Toronto Central Local Health Integration Network [email protected] Smith M4W 3R4 Naomi Ziegler SPRINT Senior Care 140 Merton Street, 2nd Floor, Toronto, ON M4S 1A1 [email protected] 15 11. North Toronto Sub-Region Advisory Council: Terms of Reference

The purpose of the North Toronto Advisory Table is to bring together leadership from across a variety of sectors, representing populations and geographies in the Sub-Region to provide a broad perspective and advance ideas through organizational support and leadership that further the health and social goals of the region. The work of the North Toronto Advisory Table will be to leverage and build on the existing work underway and support regional planning, identify how providers will collaborate to address health gaps, and improve patient experience and outcomes. The Table will be jointly chaired by Dr. Yoel Abells (Primary Care Lead) and Stacy Landau (CEO, SPRINT).

The North Toronto Advisory Table will: • Identify current and emerging issues using a population lens • Provide strategic perspective on current and emerging issues • Enable action, through strategic, cross-sectoral planning sessions, on the various initiatives underway • Encourage and facilitate collaborative problem solving and approach • Develop recommendations focused on the resolution of local system issues including creation of pathways for care that address the unmet needs of people in the Sub-Region and initiatives that help when there is no existing appropriate service to meet population care needs • Support the advancement of Quality Improvement initiatives in the region • Create a framework to determine the initial priorities to be achieved in first year

16 12. Palliative Care Journey Committee: Terms of Reference

Patients with late stage illness and their families receive care in North Toronto in a variety of care settings: in the community (home & long term care), in community settings (primary care, community service agencies etc.) and in hospital (inpatient, outpatient, palliative care units etc.). Patients and their families expect seamless and personalized care aligned with their goals. This requires clear pathways and communication to ensure planned and coordinated care by their care teams.

Service delivery partners in North Toronto are committed to working together to build and support high performing cross-sector teams who deliver timely, effective and efficient care close to home. Sunnybrook, the North Toronto hospital resource partner, together with local partners, will ensure excellent care aligned with what matters most to patients and residents with advanced illness and their families.

Key Principles • Focus on both the experience and outcomes for patients/residents and families • Adopt a needs-based and resource-matched approach to palliative care • Support the provider experience so clinicians have the appropriate competencies and access to support when needed • Provide seamless palliative care inter-professionally and inter-organizationally where appropriate.

17 13. Palliative Care Journey Committee: Network of Partners

18 14. Sunnybrook Data: Seniors

ED Admission Rate Analysis

Patients aged 70 and older

Decision Support: Michelle Martin-Rhee, Taryn Johnston, Kowchiga Ratnasingam Quality: Natalie Coyle Age 70 and older

 The ED admissions are largely driven by Age, this relationship is statistically significant

 Patients aged 70+ make up just under 1/3 of all ED visits to Sunnybrook • This is larger than Peer Teaching hospitals where patients aged 70+ make up about 1/5 of all ED visits

 Patients aged 70+ comprise nearly half of all admits – over the last 3 years, 47% of all admitted patients were 70+

 For patients 70 years and older, the admit rate is roughly 40% • This is larger than Peer Teaching hospitals where the admit rate for patients aged 70+ is roughly 30%

20 Quality Discussion Point: For patients 70 years and older, the admit rate is roughly 40%

21 70+ population: Comparison to Peers

• Patients aged 70+ make up just under a third of all ED visits at Sunnybrook – more than peer teaching facilities that have about 20%.

Ontario Peer Teaching Facilities – all visits: 2017‐18 % Less than 70 Years 81% 70 Years and over 19% TOTAL 100%

Sunnybrook- all visits: 2016‐17 2017‐18 2018‐19 YTD N%N%N% Less than 70 Years 44,992 72% 45,660 71% 11,026 72% 70 Years and over 17,642 28% 18,217 29% 4,271 28% TOTAL 62,634 100% 63,877 100% 15,297 100%

22 70+ population: Comparison to Peers

• The admit rate for 70+ is 37%-38% at Sunnybrook vs. 32% at peer teaching facilities

Ontario Peer Teaching Facilities – all visits:

Sunnybrook- all visits:

2016‐17 2017‐18 2018‐19 YTD* Not Admitted Admitted Total Not Admitted Admitted Total Not Admitted Admitted Total Less than 70 Years N 37,592 7,400 44,992 38,265 7,395 45,660 9,068 1,958 11,026 % 84% 16% 100% 84% 16% 100% 82% 18% 100% 70 Years and over N 11,201 6,441 17,642 11,352 6,865 18,217 2,690 1,581 4,271 % 63% 37% 100% 62% 38% 100% 63% 37% 100%

23 Consulting Service for Admitted Patients 70 + at Sunnybrook: 2016‐17 2017‐18 2018‐19 N%N%N% GIM 2784 45% 2868 45% 600 42% Cardiology 708 11% 707 11% 169 12% General Surgery 454 7% 507 8% 123 9% Medical Oncology 434 7% 418 7% 102 7% Critical Care 382 6% 448 7% 105 7% Orthopedic Surgery 313 5% 338 5% 71 5% Neurosurgery 212 3% 225 4% 47 3% All Others 897 15% 873 14% 211 15% Total 6,184 100% 6,384 100% 1,428 100% Under 70 70 and Over Consulting Service N % N % Consulting Service for Peer INTERNAL MEDICINE 12,941 23% 12,136 48% Teaching Facilities GENERAL SURGERY 7,387 13% 1,981 8% PSYCHIATRY 5,350 10% 261 1% CARDIOLOGY 2,694 5% 2,550 10% ORTHOPEDIC SURGERY 2,966 5% 1,779 7% OBSTETRICS AND GYNECOLOGY 3,335 6% 72 0% PEDIATRICS 2,993 5% 4 0% NEUROLOGY 1,325 2% 679 3% UROLOGY 1,252 2% 647 3% NEUROSURGERY 1,034 2% 557 2% OTOLARYNGOLOGY 1,337 2% 240 1% GASTROENTEROLOGY 1,185 2% 368 1% Source: IntelliHealth, 2017- PLASTIC SURGERY 1,242 2% 120 0% 18 NEPHROLOGY 856 2% 361 1% CRITICAL24 CARE MEDICINE 750 1% 312 1% All Others 9,177 16% 3,024 12% Time of Admission for Patients 70 and over

2016‐17 2017‐18 2018‐19 YTD* Time of Visit Completion for Admitted Patients N%N%N % 7am‐7pm 2,338 36% 2,428 35% 614 39% 7pm‐Midnight 1,735 27% 1,909 28% 406 26% Midnight ‐ 7am 2,368 37% 2,528 37% 561 35%

• Around 37% of patients aged 70 and over are admitted between midnight and 7am. • A similar percentage are admitted throughout the day (7am to 7pm), while just over a quarter are admitted between 7pm and midnight.

25 26 15. North Toronto Neighborhood-level Data

North Toronto: Population Growth (2011-2016) and Age Distribution

North Toronto 2011 - 2016 2016 Population Age group 2011 2016 % Change % of S-R % Male % Female 0-19 43,710 44,750 2% 22% 51% 49% 20-44 73,140 71,350 -2% 35% 46% 54% 45-64 52,990 55,170 4% 27% 45% 55% 65+ 29,230 32,615 12% 16% 41% 59% 65-74 14,140 17,845 26% 9% 44% 56% 75+ 15,115 14,770 -2% 7% 38% 62% Total pop. 199,055 203,700 2% 100% 46% 54% SR – Sub Region

In 2016… • Total population in North Toronto was 203,700 with 54% being female. Proportion of females was higher among seniors, particularly those aged 75+ (62%) • 84% of the population is under the age of 65. 22% of the population are children aged 0-19

From 2011 to 2016… • North Toronto had a low growth rate (2%) • Highest population growth was among those aged 65-74 (26%). There were population decreases (-2%) in young adults aged 20-44 and those aged 75+ 27 Data Source: Ontario Community Health Profile Partnership, Census‐based population denominators 2011 & 2016 15. North Toronto Neighborhood-level Data (2)

28 15. North Toronto Neighborhood-level Data (3)

Building our partnership with a focus on a “Year 1 priority population”:

Seniors living in North Toronto

North Toronto: Population of Seniors Age 65+, 2016 Census 29 15. North Toronto Neighborhood-level Data (4)

Seniors in North Toronto

1. Distribution of senior population in North Toronto, ages 65+, 2016

2. Proportion of seniors living alone in North Toronto, 1) 2) ages 65+, 2016

3. Average Rate of Low Urgency ED visits in North Toronto, ages 65+, FY15/16-FY16/17

4. Distribution of Complex Home Care Clients in North Toronto, ages 50+, FY17/18

ID Neighbourhood ID Neighbourhood 032 Englemount-Lawrence 101 Forest Hill South 039 Bedford Park-Nortown 102 Forest Hill North Bridle Path-Sunnybrook-York 041 103 Lawrence Park South Mills 056 Leaside-Bennington 104 Mount Pleasant West 097 Yonge-St.Clair 105 Lawrence Park North 099 Mount Pleasant East 106 Humewood-Cedarvale 100 Yonge-Eglinton 3) 4) 30 15. North Toronto Neighborhood-level Data (5)

As we progress in our OHT development, we will refine our potential catchment area based on how people access health services

31 16. North Toronto Neighborhood Care (1)

Neighbourhood Care Team Vision: Integrated model of care that is accountable to meeting the needs of people living within a high-density urban neighbourhood. People will experience one system that provides simple access to service, navigation / coordination if unable to self navigate, and streamlined communication of health care providers

- Local teams with neighbourhood expertise

- Simplified access and navigation

- Shared accountability and improved outcomes

Local Knowledge, Simple Access, Shared Accountability

32 16. North Toronto Neighborhood Care (2)

Together, implementing meaningful change for people, providers, and the system

Starting with core team functions, inclusive of: 1. Access to regulated health, community supports, mental health and addictions Creating positive impact in the community by: 2. Care coordination for complex clients; one care plan 3. Primary Care including Community Health Centres

Who will be supported to: • Reduce inappropriate / avoidable ED and hospital use

• Include clients and caregivers as members of the care team • Eliminating duplication (roles, assessments, communication) • Offer timely access (24/7) • Simple navigation • Test innovation and new partnerships • Improve efficiency in service delivery • Become neighbourhood experts • Improving sustainability by • Coordinate and organize care based on local need increasingly connecting ‘upstream’ • Connect to social services and local community supports (e.g. pharmacy, volunteer groups, churches, etc.) • Connect with specialized and regional care

33 16. North Toronto Neighborhood Care (3)

The Team

CSS and CMHA Home Care TEAMS Neighbourhoods Planning Leads Planning Leads Englemount Lawrence

NORTH SPRINT St. Elizabeth, VHA, TC LHIN Mount Pleasant West

Mount Pleasant East

Note: Toronto Central LHIN Primary Care Lead Yoel Abells and his team has been engaged as part of co-design for Neighbourhood Care

34 17. Patient, Family and Caregiver Engagement Committees and Activities (1)

Co-creating our engagement structures via an initial Patient and Family Council comprised of members from our respective engagement bodies.

The scope and breadth of client, patient, family and caregiver involvement includes, but is not limited to providing advice and feedback on:

 Strategic planning

 Governance

 Polices

 Programs and services

 Communications

We will leverage our Collaborative’s extensive experience to integrate the patient experience into the work of the North Toronto Ontario Health Team.

35 18. North Toronto Areas of Activity (1) Early areas of activity

1. Priority initiatives to enhance care in North Toronto

• Population Health Management System • Neighbourhoods and specific populations living in North Toronto • Program identification and simplification for enhanced access (year 1 priority population: seniors) • Patient engagement and co-design • Set targets for hospital diversion (ED and Inpatient Admissions) • Plan for equity in access to services 2. Measuring improvement

• Assessing local need (baselining) • Measuring health outcomes and experience • Ability to track our progress and impact as a future Ontario Health Team

3. Integration Agreement and Partnership Agreement / Joint Venture

Orienting on common Facilitating Identified and committed primary care purpose collaboration • CHC leadership • Goals, objectives, guiding Focusing on service • Inclusion of primary care organizations principles integration to meet local • Support for solo physicians with appropriate • Participatory approach needs support (SPIN, SCOPE, etc.)

4. Data infrastructure and decision support

• Mapping IT assets, programs, providers, and initiatives • Assessing data sharing across providers • Building upon existing platforms (e.g. portals) and identifying opportunities for linkages • Identifying opportunities for predictive analytics

36 19. Building & Integrating Primary Care in Toronto (1)

37